To Test or Not to Test (for ADHD)?

Attention Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that is characterized by difficulty with sustained attention, hyperactivity, and/or impulsivity. Some kids mostly have difficulty with attention (referred to as ADHD, Predominantly Inattentive Presentation, formerly called ADD), some kids mostly have symptoms of hyperactivity and impulsivity (referred to as ADHD, Predominantly Hyperactive-Impulsive Presentation), and some kids have difficulty with both attention and hyperactivity/impulsivity (referred to as ADHD, Combined Presentation).

The diagnosis of ADHD can be very straightforward for a subset of children. These kids may demonstrate highly impairing, overt symptoms of ADHD, often from a young age. These children tend to have symptoms of hyperactivity and impulsivity that are quickly noted by parents and preschool or kindergarten teachers. This group of children may appear as if they are driven by a motor or always on the go, and they have trouble paying attention within a very short period of time. The diagnosis of ADHD for this subset of children is frequently made by a pediatrician after parents and teachers complete a questionnaire (often the Vanderbilt Assessment Scale) and the child scores above a certain threshold.

However, the larger majority of children exhibit symptoms of inattention, hyperactivity, and impulsivity that are not as overt or clear cut. This may present as a lack of focus for certain tasks or in certain situations, daydreaming or distractibility, poor attention to detail or rushing through work, talking constantly, or fidgeting. Parent and teacher questionnaires may show levels of inattention and hyperactivity/impulsivity that are above the threshold, but this subset of children would greatly benefit from testing to confirm the diagnosis. That is because there are many other reasons why a child may be distracted, inattentive, rush through their work, not start a task independently, fidget, or chat excessively. Here are a few examples:

• A child with anxiety may be distracted because they are focused on their worries (e.g., “I forgot to study for my next period’s test!” “What if people laugh at me when it’s my turn to read aloud?”). They may rush through their work because they are worried about completing the test in the allotted time period or have trouble starting a task as they “freeze.” They may fidget or talk excessively when feeling nervous.
• A child with a learning disability may zone out or appear distracted when they are having trouble understanding a concept or completing an assignment. They may get bored or frustrated and begin to move around in their seat, and they may rush through their work to get it done as quickly as possible out of embarrassment. They may also have trouble starting a task independently as they do not know how to complete the work.
• A child with a language disorder may become inattentive and distracted when they cannot understand what the teacher is saying. They may become fidgety and “check out,” and they may not start tasks independently as they did not understand the task instructions.

These example children (a child with ADHD, anxiety, a learning disability, and a language disorder) may all present in a similar fashion, with the same behaviors endorsed on a questionnaire (e.g., does he have trouble paying attention? Is he fidgety or restless?). But the reasons why these behaviors are occurring are fundamentally different. Making an accurate diagnosis is critical to getting the right treatment plan in place. We would not want to treat a child with a stimulant medication if the underlying cause of inattention is a language disorder, just as we would not recommend speech and language therapy for a child with ADHD (without language issues).

This is where testing comes into play. A neuropsychological assessment is an excellent tool for teasing out the underlying root cause behind the surface symptoms. A comprehensive neuropsychological assessment, such as the ones done at NESCA, assesses a child’s intellectual ability, academic skills (e.g., reading, writing, math), expressive and receptive language skills, visual-spatial skills, learning and memory style, fine motor skills, attention and executive functioning, social-emotional well-being, and adaptive living skills. This breadth and depth of testing can help to rule out alternative explanations and ensure that attention difficulties are truly caused by ADHD.

Testing also allows us to compare a child’s performance on testing to a sample of children the same age. This objective information is considered along with a host of other information (e.g., history given by the parents/caregivers, record review, questionnaires completed by parents and teachers, behavioral observations during testing). This comprehensive evaluation provides a great deal of information and increases the likelihood of an accurate diagnosis and effective treatment plan.

 

About the Author

NESCA is a pediatric neuropsychology practice and integrative treatment center with offices in Newton, Plainville, and Hingham, Massachusetts; Londonderry, New Hampshire; the greater Burlington, Vermont region; and Brooklyn, New York (coaching services only) serving clients from infancy through young adulthood and their families. For more information, please email info@nesca-newton.com or call 617-658-9800.